History: Age at onset Presence or absence of aura and prodrome Frequency, intensity and duration of attack Number of headache days per month Time and mode of onset Quality, site, and radiation of pain Associated symptoms and abnormalities Family history of migraine Precipitating and relieving factors Effect of activity on pain Relationship with food/alcohol Response to any previous treatment Any recent change in vision Association with recent trauma Any recent changes in sleep, exercise, weight, or diet State of general health Change in work or lifestyle (disability) Change in method of birth control (women) Possible association with environmental factors Effects of menstrual cycle and exogenous hormones (women)
Brief Headache Screen:Daily/3-4 days per week/ 1-2 days per week/ 1-3 days per month/ 1x a month to 1x per year/almost never 1. How often do you get severe headaches (ie, without treatment it is difficult to function)? 2. How often do you get other (milder) headaches? 3. How often do you take headache relievers or pain pills? 4. Has there been any recent change in your headaches? Presence of episodic disabling headache correctly identified migraine in 93% with episodic migraine and 78% with chronic headache with migraine.
Physical Exam: BP/Pulse Bruit at neck, evaluate eyes, and head for clinical signs of AVM Palpate the head, neck, and shoulder regions Check temporal and neck arteries Examine the spine and neck muscles A functional neurologic examination including getting up from a seated position without any support, walking on tiptoes and heels, cranial nerve examination, fundoscopy and otoscopy, tandem gait and Romberg test, and symmetry on motor, sensory, reflex and cerebellar (coordination) tests, Plantar reflex(to evaluate UMN)
Warning signs on EXAM: Neck stiffness/meningismus Papilledema suggests the presence of an intracranial mass lesion, benign intracranial hypertension (pseudotumor cerebri), encephalitis, or meningitis Focal neurologic signs suggest an intracranial mass lesion, arteriovenous malformation, or collagen vascular disease
Characteristics of headache with serious underlying pathology:
History:
Explosive onset and severe at onset
No similar headaches in the past
Concomitant infection
Altered mental status
Headache with exertion
Age over 50
Immunosuppression
Physical examination:
Neurologic abnormalities
Decreased level of consciousness
Meningismus
Toxic appearance
Papilledema
Imaging Indicated in: Nonacute headache + unexplained abnormal finding on neurologic examination. Unclear indication with absence of neurologic symptoms (eg, headache worsened by Valsalva, causing awakening from sleep, new headache in older population, or progressively worsening headache). Not warranted for patients with migraine and a normal neurologic examination, unless patient has atypical migraine features Recent significant change in the pattern, frequency or severity of headaches Progressive worsening of headache despite appropriate therapy Focal neurologic signs or symptoms Onset of headache with exertion, cough, or sexual activity Orbital bruit Onset of headache after age 40 years Once you have ruled out a Life Threatening Headache move on to Diagnosis and Treatment:
Primary Tension-type Migraine Cluster
Secondary(2% of HA) Meningitis SAH Tumor Stroke/TIA Temporal Arteritis
Recognizing the pattern of primary HA +FH stereotypic headache pattern over time Menstrual association Prodromes and/or aura Resolution with sleep Changing location of HA Otherwise healthy
1. Tension-type HA: At least 10 previous episodes from 30 minutes to 7 days characterized by at least 2 of the following pain characteristics: Pressing,tightening, non pulsatile quality Mild or moderate intensity (may inhibit but does not prohibit activity) Bilateral location Not aggravated by routine physical activity
And both of the following: No n/v Photophobia or phonophobia may be present but not both
Tension HA Treatment: Episodic: Tylenol, NSAID, caffeine Butalbital/narcotics
Chronic: Amitriptyline, mirtazapine Stretching, massage, exercise, ergonomic adjustment Mind-body tx -biofeedback -CBT -stress management and relaxation training Beware of prolonged use of narcotics b/c can get rebound HA and dependence
2. Migraine without Aura: At least 5 headache attacks lasting 4-72 hours characterized by at least two of the following characteristics: Unilateral pain throbbing/pulsatile moderate to severe in intensity aggravation by routine activity In addition at least 1 of the following: nausea +/- vomiting photophobia and /or phonophobia Diagnosis should include at least 5 previous attacks and no evidence of underlying disease
3. Migraine with aura: Headache follows attacks. Fulfilling at least 3 of the following: 1 or more fully reversible visual symptoms with either positive or negative features, and also includes sensory or speech symptoms At least 1 aura symptoms develops gradually over more than 4 minutes or 2 or more symptoms occur in succession No aura symptom lasts more than 60 minute Headache follows aura with a free interval of less than 60 minutes (May also begin simultaneously with the aura)
Risk Factors for Migraine HA: Hormonal fluctuations Chronobiologic/abrupt changes Vasodilator use Drugs Sensory input Emotional stress Trauma-emotional/physical
With Diagnosis of Migraine: Depression is 3x more common Anxiety and panic dx are 6-8x more common IBS 8x more common Stroke 4x more common
Migraine Treatment: Prodrome: Tylenol, high dose NSAID
Abortive therapy: Triptans(Sumatriptan) DHE Tylenol NSAID Phenothiazines: Metoclopromide IV or IM Valproic acid Opiods: avoid if possible can develop chronic migraine after receiving parenteral opiods Magnesium sulfate: 1 g loading dose Olanzapine: 10mg dose Other options: Injection/block: occipital nerve block, trigger point, botox Occipital nerve stimulator PT/Mind body Alternative: Petadolex( petasites hybridus, butterbur) magnesium, feverfew, riboflavin(B2), coenzyme Q10 NO MELATONIN Hormone manipulation: decrease estrogen drop at menopause, DO NOT USE IN MIGRAINE WITH AURA
4. Cluster HA: At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated, with one or more of the following signs occurring on the same side as the pain Conjunctival injection Lacrimation Nasal congestion Rhinorrhoea Forehead and facial sweating Miosis Ptosis Eyelid edema
Associated factors: 9:1male to female, may have seasonal variations, usually no n/v, restlessness and agitation
Risk factors Cluster HA: ETOH Cig Cold wind exposure Heat blown in face Seasonal
Cluster HA treatment: Acute: high flow oxygen 10L/min for 10min or 7L/min for 15min oral medications usually ineffective injectable sumatriptan 6mg SQ DHE 1mg SQ/IM/IV/intranasal intranasal lidocaine- 1ml of 10% via cotton swab
Non acute: Verapamil 360-480mg/day Lithium 900mg QD Depakote 250mg BID Prednisone 60mg daily and taper over 2-3 wks for new/recurrent cluster headache Anti-seizure medication: topiramate, gabapentin
Sinus HA: Not a primary HA Frequent migraine misdiagnosis Presents with fever, purulent nasal d/c, acute sinusitis
Age at onset
Presence or absence of aura and prodrome
Frequency, intensity and duration of attack
Number of headache days per month
Time and mode of onset
Quality, site, and radiation of pain
Associated symptoms and abnormalities
Family history of migraine
Precipitating and relieving factors
Effect of activity on pain
Relationship with food/alcohol
Response to any previous treatment
Any recent change in vision
Association with recent trauma
Any recent changes in sleep, exercise, weight, or diet
State of general health
Change in work or lifestyle (disability)
Change in method of birth control (women)
Possible association with environmental factors
Effects of menstrual cycle and exogenous hormones (women)
Brief Headache Screen: Daily/3-4 days per week/ 1-2 days per week/ 1-3 days per month/ 1x a month to 1x per year/almost never
1. How often do you get severe headaches (ie, without treatment it is difficult to function)?
2. How often do you get other (milder) headaches?
3. How often do you take headache relievers or pain pills?
4. Has there been any recent change in your headaches?
Presence of episodic disabling headache correctly identified migraine in 93% with episodic migraine and 78% with chronic headache with migraine.
Physical Exam:
BP/Pulse
Bruit at neck, evaluate eyes, and head for clinical signs of AVM
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles
A functional neurologic examination including getting up from a seated position without any support, walking on tiptoes and heels, cranial nerve examination, fundoscopy and otoscopy, tandem gait and Romberg test, and symmetry on motor, sensory, reflex and cerebellar (coordination) tests, Plantar reflex(to evaluate UMN)
Warning signs on EXAM:
Neck stiffness/meningismus
Papilledema suggests the presence of an intracranial mass lesion, benign intracranial hypertension (pseudotumor cerebri), encephalitis, or meningitis
Focal neurologic signs suggest an intracranial mass lesion, arteriovenous malformation, or collagen vascular disease
Characteristics of headache with serious underlying pathology:
History:
Imaging Indicated in:
Nonacute headache + unexplained abnormal finding on neurologic examination.
Unclear indication with absence of neurologic symptoms (eg, headache worsened by Valsalva, causing awakening from sleep, new headache in older population, or progressively worsening headache).
Not warranted for patients with migraine and a normal neurologic examination, unless patient has atypical migraine features
Recent significant change in the pattern, frequency or severity of headaches
Progressive worsening of headache despite appropriate therapy
Focal neurologic signs or symptoms
Onset of headache with exertion, cough, or sexual activity
Orbital bruit
Onset of headache after age 40 years
Once you have ruled out a Life Threatening Headache move on to Diagnosis and Treatment:
Primary
Tension-type
Migraine
Cluster
Secondary(2% of HA)
Meningitis
SAH
Tumor
Stroke/TIA
Temporal Arteritis
Recognizing the pattern of primary HA
+FH
stereotypic headache pattern over time
Menstrual association
Prodromes and/or aura
Resolution with sleep
Changing location of HA
Otherwise healthy
1. Tension-type HA:
At least 10 previous episodes from 30 minutes to 7 days characterized by at least 2 of the following pain characteristics:
Pressing,tightening, non pulsatile quality
Mild or moderate intensity (may inhibit but does not prohibit activity)
Bilateral location
Not aggravated by routine physical activity
And both of the following:
No n/v
Photophobia or phonophobia may be present but not both
Chronic version 15d/month add nausea
Risk Factors for tension HA:
Musculoskeletal condition
Stress
Anxiety
Fatigue
Anger
Poor posture/ergonomics
Tension HA Treatment:
Episodic:
Tylenol, NSAID, caffeine
Butalbital/narcotics
Chronic:
Amitriptyline, mirtazapine
Stretching, massage, exercise, ergonomic adjustment
Mind-body tx
-biofeedback
-CBT
-stress management and relaxation training
Beware of prolonged use of narcotics b/c can get rebound HA and dependence
2. Migraine without Aura:
At least 5 headache attacks lasting 4-72 hours characterized by at least two of the following characteristics:
Unilateral pain
throbbing/pulsatile
moderate to severe in intensity
aggravation by routine activity
In addition at least 1 of the following:
nausea +/- vomiting
photophobia and /or phonophobia
Diagnosis should include at least 5 previous attacks and no evidence of underlying disease
3. Migraine with aura:
Headache follows attacks. Fulfilling at least 3 of the following:
1 or more fully reversible visual symptoms with either positive or negative features, and also includes sensory or speech symptoms
At least 1 aura symptoms develops gradually over more than 4 minutes or 2 or more symptoms occur in succession
No aura symptom lasts more than 60 minute
Headache follows aura with a free interval of less than 60 minutes (May also begin simultaneously with the aura)
Risk Factors for Migraine HA:
Hormonal fluctuations
Chronobiologic/abrupt changes
Vasodilator use
Drugs
Sensory input
Emotional stress
Trauma-emotional/physical
With Diagnosis of Migraine:
Depression is 3x more common
Anxiety and panic dx are 6-8x more common
IBS 8x more common
Stroke 4x more common
Migraine Treatment:
Prodrome: Tylenol, high dose NSAID
Abortive therapy:
Triptans(Sumatriptan)
DHE
Tylenol
NSAID
Phenothiazines: Metoclopromide IV or IM
Valproic acid
Opiods: avoid if possible can develop chronic migraine after receiving parenteral opiods
Magnesium sulfate: 1 g loading dose
Olanzapine: 10mg dose
Other options:
Injection/block: occipital nerve block, trigger point, botox
Occipital nerve stimulator
PT/Mind body
Alternative: Petadolex( petasites hybridus, butterbur) magnesium, feverfew, riboflavin(B2), coenzyme Q10
NO MELATONIN
Hormone manipulation: decrease estrogen drop at menopause, DO NOT USE IN MIGRAINE WITH AURA
Prophylactic:
Inderal 60-240mg daily
Depakote 250mg BID
Amitriptyline/Nortriptyline 10-100mg qhs
Verapamil 180-240mg Daily
Naproxen 500mg BID
Neurontin 100-600mg TID
4. Cluster HA:
At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated, with one or more of the following signs occurring on the same side as the pain
Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhoea
Forehead and facial sweating
Miosis
Ptosis
Eyelid edema
Associated factors: 9:1male to female, may have seasonal variations, usually no n/v, restlessness and agitation
Risk factors Cluster HA:
ETOH
Cig
Cold wind exposure
Heat blown in face
Seasonal
Cluster HA treatment:
Acute:
high flow oxygen 10L/min for 10min or 7L/min for 15min
oral medications usually ineffective
injectable sumatriptan 6mg SQ
DHE 1mg SQ/IM/IV/intranasal
intranasal lidocaine- 1ml of 10% via cotton swab
Non acute:
Verapamil 360-480mg/day
Lithium 900mg QD
Depakote 250mg BID
Prednisone 60mg daily and taper over 2-3 wks for new/recurrent cluster headache
Anti-seizure medication: topiramate, gabapentin
Sinus HA:
Not a primary HA
Frequent migraine misdiagnosis
Presents with fever, purulent nasal d/c, acute sinusitis
Links:
Headache Progress Note:
Headache diary:
http://www.headaches.org/For_ Professionals/Headache_Diary
Excercises For Migraine:
http://www. straightenupamerica.org/ Handouts/Handouts.html
AAFP Articles:
http://www.aafp.org/afp/ topicModules/viewTopicModule. htm?topicModuleId=10